We tracked DAH provided and received by the MENA region from 2000 to 2017 using methods developed by IHME . We defined DAH as the in-kind and financial resources transferred to low- and middle-income countries with the primary goal to maintain or improve health. We captured flow of resource for DAH from originating sources, through disbursing agencies (channel), and to recipient and health focus area.
Our definition of the MENA region is based on the Global Burden of Disease super-region where countries were divided to seven super-regions. Global Burden of Disease super-region categorizes countries based on geographic closeness and epidemiological similarity . Countries and territories included for analysis were Afghanistan, Algeria, Bahrain, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Sudan, Syria, Tunisia, Turkey, United Arab Emirates, and Yemen.
To generate DAH provided by the MENA region, we leveraged official development assistance data reported to OECD DAC, project-level and aggregate-level government agency budgets, annual reports, as well as financial statements from key international development agencies. After initial literature review, we restricted the bilateral aid sources to Saudi Arabia, Kuwait and United Arab Emirates, as these three individual donors provided the majority – over 90% - of official development assistance from MENA region . We also included aid contributions to multilateral entities such as the United Nations agencies from these three donors and other MENA countries (Afghanistan, Algeria, Bahrain, Egypt, Iran, Iraq, Jordan, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Sudan, Syria, Tunisia and Turkey). Additionally, we captured DAH disbursed through the Islamic Development Bank, selected among various regional financial institutions due to data availability.
We estimated DAH provided to all MENA countries using data from IHME’s Financing Global Health 2018 Development Assistance for Health database (which includes project-level disbursement information of DAH from key development agencies) , in addition to data from the above-mentioned donors to capture the internal transfer of resources within the MENA region. Our channels of DAH included bilateral aid agencies, development banks, United Nations agencies, public-private partnerships, non-governmental organizations and foundations. A step-by-step method of how we produced the estimates can be found in the Additional file 1.
As the delivery and implementation of loans and grants requires that donor/grant making institutions incur some additional cost in terms of program management and staffing, we also calculated administrative expenses for Saudi Arabia, Kuwait and United Arab Emirates. We defined administrative expenses as the costs associated with administering grants and loans, which includes costs related to staffing and program management. Due to the lack of data, we used the average administrative cost ratio of selected development assistance agencies with more available information (from the United States, United Kingdom, Japan, Sweden and Norway) as a proxy for all the bilateral agencies, which was 12.8% .
Estimating DAH disbursed through Saudi Arabia’s bilateral agencies
We generated the estimate of bilateral DAH contributions from Saudi Arabia through aggregating health-related concessional loans disbursed through the Saudi Fund for Development (SFD) and grants disbursed by the Saudi Arabia’s government agencies . For Saudi Fund for Development concessional loans, we extracted 2002–2017 project-level commitment data from the Fund’s annual reports and websites  and calculated the health proportion of total loans. Since we only have project-level commitment in the Saudi Fund for Development reports, we included total official development assistance disbursement data using data from the 2000–2014 DAC table (total flows by type by DAC donor) extracted from OECD database (we did not use the 2015–2017 data points due to the note which said “the 2015, 2016 and 2017 activity-level data presented for Saudi Arabia are incomplete”) . We used the disbursement data to rescale project-level commitment data, to reflect the actual disbursement to commitment difference of each health concessional loan. For each individual loan, annual disbursement was estimated by dividing the total disbursement by project length, using project-level information from the annual reports and websites of all projects. For projects without a closing date, estimates were based on the average project length. We predicted 2015–2017 data using 3-year weighted average ratio of commitment and disbursement data.
For the grant-disbursing agencies, we conducted a literature and data search. we found a number of agencies that work on health and mostly humanitarian activities . These agencies included the King Abdullah International Foundation for Humanitarian Activities, King Salman Humanitarian Aid and Relief Center, Saudi Campaigns, Saudi Red Crescent Authority and other governmental entities . These agencies do not have project-level databases and mostly do not publish public annual reports, and all of their DAH activities reported to the OECD creditor reporting system (CRS) database are health-related humanitarian aid, thus we extracted their 2000–2017 project-level information from the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) Financial Tracking Service website, which has a longer time-series and more detailed project-level information . We included only health projects that were marked as “paid contribution” and excluded “pledged” or “committed” contributions. Since UNOCHA only captures the humanitarian projects, our estimate of Saudi Arabia’s DAH is a very modest estimate. We aggregated the loans and grants to obtain our Saudi Arabia bilateral DAH.
Estimating DAH disbursed through Kuwait’s bilateral agencies
The Kuwait Fund for Arab Economic Development is the only aid-disbursing agency in Kuwait, providing concessional loans and also administering government grants . We extracted 2000–2017 project-level commitment data from the Fund’s annual report and website , and similarly calculated the health proportion of concessional loans, adjusted the commitment to disbursement amount using 2000–2017 DAC table (total flows by type by DAC donor) extracted from OECD database . For each individual concessional loan, annual disbursement was estimated by dividing the total disbursement by project length, using project-level information from the annual reports and websites of all projects. For projects without a closing date, estimates were based on the average project length. All grants projects did not have a reported start and closing date so we assumed that the projects were disbursed in the year that they were signed since these grants were usually small and were mostly feasibility or pilot grants.
Estimating DAH disbursed through United Arab Emirates’ bilateral agencies
United Arab Emirates (UAE) became an OECD DAC participant country in 2014 and we extracted UAE’s bilateral DAH contribution from IHME’s Financing Global Health 2018 Development Assistance for Health database .
Estimating DAH disbursed through multilateral organizations and public-private partnerships
We used data from IHME’s Financing Global Health 2018 Development Assistance for Health database to estimate DAH contributions from the MENA country donors to multilateral aid agencies. The multilateral aid agencies of interest include UN agencies (the World Health Organization, the United Nations Population Fund (UNFPA), the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Children’s Fund (UNICEF)), the World Bank, the Global Fund, regional development banks including the African Development Bank and the Islamic Development bank, as well as non-governmental organizations.
Among various regional financial institutions that potentially work on health sector, we only included the Islamic Development Bank (IsDB). We excluded the rest of multilateral agencies (Arab Fund for Economic and Social Development, Arab Bank for Economic Development in Africa, OPEC fund for International Development, the Arab Gulf Program for Development) due to their relatively small size in volume of DAH disbursed and lack of adequate project-level information for 2000–2017. Our estimates of IsDB was also restricted to the Ordinary Capital Resources (OCR, concessional loans with 15–25 years’ maturity and 3–7 years’ grace period, service fee up to 1.5%)  and did not include the Special account Waqf Fund or Islamic Solidarity Fund for Development due to data availability. We extracted project-level commitment data for IsDB from the CRS database and adjusted the commitment to disbursement amount using total gross disbursement data extracted from OECD DAC table (official development assistance disbursements by donor) . We also calculated administrative expenses using IsDB year-specific administrative cost ratio based upon information extracted from the annual reports . Reasons for exclusion of the above-mentioned entities and detailed description of the original methodology used to obtain the estimates can be found in the Additional file 1.
Estimating the health focus areas and recipients of DAH from MENA
For each individual channel as described above, we also included an analysis of the composition of health funding by recipient country and health focus area. We conducted a keyword search on each individual project description to disaggregate the health focus area (HIV/AIDS, tuberculosis, malaria, reproductive and maternal health, newborn and child health, other infectious diseases, non-communicable diseases, health system strengthening/sector-wide approaches (SWAps)).
Comparing DAH provided and received by MENA region
We compared DAH contributions from the MENA region and DAH provided to the MENA region using data extracted from the Financing Global Health 2018 database. We calculated DAH provided and received by each individual country in 2017, annualized rate of change from 2010 to 2017, as well as the three largest disbursing agencies of DAH provided or received in 2017.
Finally, we compared DAH provided by the three largest donor countries in the MENA region (United Arab Emirates, Kuwait and Saudi Arabia) and their relative gross domestic products and government spending to examine the level of DAH in relative to their national economy and general government spending. All analysis was completed using Stata version 13. We reported DAH contributions in constant 2018 US dollars.